Sarah T. Melton, PharmD,BCACP, BCPP,CGP,FASCP

Screening, Brief Intervention and Referral to Treatment (SBIRT) in the Primary Care Setting

16th Annual Primary Care ConferenceMonday , March 26, 2012

Millennium Centre, Johnson City, TN

ObjectivesAt the completion of this presentation, the participant will be able to:

1. Describe the steps involved in proper screening, brief intervention, and referral to treatment (SBIRT) for substance abuse in the primary care setting.

2. Select the appropriate tools to screen for alcohol and drug abuse in the primary care setting.

3. Apply the principle of motivational interviewing and stages of change in the SBIRT process.

4. Examine principles of coding, billing and reimbursement for SBIRT in the primary care setting.

What is SBIRT?SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment servicesFor persons with substance use disordersThose who are at risk of developing these disorders

Primary care centers, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users

Before more severe consequences occur

SBIRT: Core Clinical ComponentsScreening: Very brief screening that identifies

substance-related problemsBrief Intervention: Raises awareness of risks and

motivates patient toward acknowledgement of problemBrief Treatment: Cognitive behavioral work with

patients who acknowledge risks and are seeking helpReferral: Referral of those patients with more serious

addictions for outpatient or inpatient treatment

Nationwide Movement Toward Standard of Care

US Preventive Services Task Force The Patient Protection and Affordable Care Act 2010$240 million in federal SBIRT funding to states and

residency training programs (ETSU!)NIH fundingJACHO – proposed standardReimbursement codes - Centers for Medicare &

Medicaid Services; the AMA (CPT codes) and E&M codes

Evidence to Support SBIRT in Primary Care

Systematic review of 22 randomized controlled trials (RCT) of brief alcohol interventions in primary care settings 15 minutes or less At least one follow-up

Average number of drinks/week reduced by 4 drinks over controls

10-19% more participants drinking at moderate or safe levels than controls

One study showed maintenance of improved drinking for up to 48 months

Whitlock EP, Polen MR, Green CA, et al. Annals Int Med 2004;104(7):557-580. Kaner EF, Dickinson HO, Beyer F, et al. Drug Alcohol Rev 2009; 28(3):301-23.

Evidence to Support SBIRT in Primary Care

A meta-analysis suggests an overall reduction of 56% in number of drinks consumed per week

The effect size for a brief motivational intervention of all types ranged from 0.25 to 0.57, with participants followed from 3 to 24 months

Research has shown brief interventions can reduce alcohol use for at least 12 months in patients who are not alcohol dependent

10-30% of patients can be expected to change their drinking behaviors as a result of a brief intervention

Burke BL, Arowitz H, Menchola M.Consult Clin Psychol 2003;71(5):843-6; Babor TF, Higgins-Biddle JC. Addiction 2000;95(5):677-86. Fleming M, Manwell LB. Alcohol Res Health 1999;23(2):128-37.

SBIRT Prospective Cohort Study 6 clinical sites 459,599 patients screened Hazardous use or current

substance abuse disorder: 22.7%

At 6-month follow up Drug use 67.7% ↓ Alcohol use 38.6% ↓ Self reported improvement in

general health, mental health, employment, housing status and criminal behavior

70%

14%

16%

Brief Intervention Brief Treatment Specialty Treatment

Madras BK, Compton WM, Avula D, et al., Drug Alcohol Depend 2009;99:280-95.

Major Impact on Public Health?

Stem progression to dependence

Improve medical conditions exacerbated by substance abuse

Prevent medical conditions resulting from substance abuse or dependence

Reduce drug-related infections and infectious diseases

Improve response to medications

Identify those at higher risk of abusing prescription drugs

Identify abusers of prescription drugs or OTC drugs

Have positive influence on social function

Characteristics of a Good Screening Tool

Brief (10 or fewer questions)FlexibleEasy to administer, easy for patientAddresses alcohol & other drugsIndicates need for further assessment or

interventionHas good sensitivity and specificity

Sensitivity and specificitySensitivity refers to the ability of a test to

correctly identify those people who actually have a problem, e.g., “true positives”

Specificity is a test’s ability to identify people who do not have a problem, e.g., “true negatives”

Good screening tools maximize sensitivity and reduce “false positives”

SBIRT GoalsIncrease access to care for persons with

substance use disorders and those at risk of substance use disorders

Foster a continuum of care by integrating prevention, intervention, and treatment services

Improve linkages between health care services and alcohol/drug treatment services

Poll the AudienceWhat percentage of your primary care

patients would be classified with alcohol abuse or dependence?

What percentage would be classified as “at risk” drinkers?

What percentage of your primary care patients have used illicit drugs in the past month?

Compare DemographicsHow did your answers compare with statistics

for the general population? Percent with alcohol abuse or dependence

• 7% or about 1 in 14 Percent “at risk” drinkers

• 23% or nearly 1 in 4! Percent using illicit drug

• 8% or about 1 in 12

SAMHSA, National Survey on Drug Use and Health, 2008Ages 12+ in the United States

SCREENING WIDENS THE NETSCREENING WIDENS THE NET

ABSTAINERS & LOW RISK USE

AT-RISK ALCOHOL & DRUG

USE

ABUSE/ DEPENDENCE

Primary Prevention

Brief Intervention

Specialized Treatment

Why Screen?

Annual Screen Description

One question regarding alcohol use One question regarding drug use

Method Written form given once a year by front office at

check-in Verbally once a year at triage or by nursing when

patient is being roomed Pre-screens are NOT reimbursable

Purpose Quickly identify patients at risk of misusing alcohol or

drug and warrant further screening

Annual ScreeningOnce a year, all our patients are asked to complete this form because drug use, alcohol use, and mood can affect your health as well as medications you may take. Please help us provide you with the best medical care by answering the questions below.

Full Screen Description

The AUDIT (Alcohol Disorder Identification Tool) is a 10-item questionnaire for alcohol use

The DAST-10 (Drug Abuse Screening Tool) is a 10-item questionnaire for drugs

Method Given to patients who are positive on annual screen Written form(s) given when patient is taken into exam room by

nursing Purpose

Stratify patients into zones of substance use and informing the clinician who does a brief intervention

The AUDIT• Developed by World

Health Organization

• Accurate measure of risk

across gender, age, &

cultures

• 3 domains of drinking

• Scores 8 > indicate risky

drinking

• Scores 20 > may indicate

need of treatment

The AUDIT

Advantages:Validated on primary health care patients

in six countriesIdentifies hazardous and harmful alcohol

use as well as possible dependenceBrief, rapid, and flexibleCan be administered as questionnaire or

interview

The AUDIT

Limitations:Limited to alcohol screeningMay be too lengthy for some situations

(e.g. emergency department)Not enough research has been completed

to determine precise cut-off points

DA

ST

-10

DAST-10

Advantages:Brief and inexpensiveProvides a quantitative index of the extent

of problems related to drug abuseCan be administered to adults as well as

adolescentsCan be administered as questionnaire or

interview

DAST-10

Limitations:Does not screen for alcohol use/abuseClients may “fake” resultsScores may be misinterpretedShould NOT be administered to persons

actively under the influence of drugs or who are undergoing drug withdrawal reaction

Scoring the DAST-10

For questions 1 & 2, score “1” for every “YES” response

For question 3, score “1” for a “NO” response

For questions 4-10, score “1” for every “YES” response

Scoring the DAST-10Score Degree of Problem

0 None Reported 1-2 Low Level 3-5 Moderate Level 6-8 Substantial Level 9-10 Severe Level

DAST Interpretation Guide

Score Action ASAM

0 Monitor None 1-2 Brief Counseling Level I 3-5 Outpatient Level I or II 6-8 Intensive Level II or III 9-10 Intensive Level III or IV

ASAM = American Society of Addiction Medicine level/category

Brief Intervention Description

Evidence-based and can be performed in as little as 3 minutes, typically 5-15 minutes

Based on motivational interviewing Method

Delivered by the clinician after the full screen has been scored

Purpose Motivate patients to reduce their use, abstain, or

accept a referral to treatment

Effectiveness of Brief Intervention

32 controlled studies found brief interventions often as effective as more extensive treatments

Reduction in the following as a result of brief intervention: Alcohol and other substance consumption/use Harmful physical consequences Social consequences Sick days, missed work Hospitalizations Trauma/accidents/injuries

Fleming M, Manwell LB. Alcohol Res Health 1999;23(2):128-37.

What is Motivational Interviewing?Helps identify and encourage behavior changeIncrease patient’s awareness of problems,

consequences, and risks related to behaviorAssists patient to explore and resolve

ambivalence toward behavior and increase motivation to change

Motivation to change is elicited from the person, not mandated from the outside

Principles of Motivational Interviewing

Express empathyDevelop discrepancyRoll with resistanceSupport self-efficacy

Four Components of Brief InterventionRaise the subjectProvide feedbackEnhance motivationNegotiate and advise

Would you mind taking a few minutes to talk about your [X] use? Before we go further, I’d like to learn a little more about you.What is a typical day like for you?Where does your [X] use fit in?

1. Build rapport

Raising the Subject

Help me understand through your eyes the good things about using [X]? What are some of the not so good things about using [X]?

2. Ask about Pros & Cons

So on the one hand you said <PROS>, and on the other hand <CONS>. Summarize

Ask permission

Give information

Elicit reaction

Providing Feedback

I have some information on low-risk guidelines for drinking, would you mind if I shared them with you?

We know that drinking • 4 or more (F)/ 5 or more (M) drinks in 2 hours • more than 7(F)/14(M) drink in a week • use of illicit drugs can put you at risk for illness and injury. It can also cause health problems like [insert medical information].

What are your thoughts on that?

3. Feedback

4. Readiness to Change This Readiness Ruler is like the Pain Scale we use to measure pain levels. On a scale from 1-10, with one being not ready at all and 10 being completely ready, how ready are you to change your [X] use? You marked ___. That’s great. That means you’re ___% ready to make a change.

Why did you choose that number and not a lower one like a 1 or 2?

Readiness ruler

Reinforce positives

Assessing Readiness to Change

Categories of drinking

0cm 1 2 3 4 5 6 7 8 9 10

IIIIV

I Low risk or

Abstain: 78%

Dependent: 5%

IIHarmful: 8%

Risky: 9%

SBIRT READINESS RULER

Low-risk drinking limits

• “If it’s okay with you, let’s take a minute to talk about the annual screening form you’ve filled out today.”

Raise the subject

• “As your doctor, I can tell you that drinking (drug use) at this level can be harmful to your health and possibly responsible for the health problem you came in for today.”

Provide feedback

“On a scale of 0-10, how ready are you to cut back your use?”• If >0: “Why that number and not a ____ (lower one)?” •If 0: “Have you ever done anything while drinking (using

drugs) that you later regretted?”

Enhance motivation

• “What steps can you take to cut back your use?”• “How would your drinking (drug use) have to impact your life

in order for you to start thinking about cutting back?”

Negotiate plan

I Low risk/AbstainAUDIT: 0–7 DAST: 0

II RiskyAUDIT: 8–15 DAST: 1-2

III HarmfulAUDIT: 16-19 DAST: 3-5

IV DependentAUDIT: 20+ DAST: 6+

Not at all

Very

SA

MH

SA

Ref

erra

l Hel

plin

e1-

800-

662-

HE

LP

Stages of ChangeProchaska & DiClemente

Create action plan What are some options/steps that will work for you? What do you think you can do to stay healthy and safe?

Tell me about a time when you overcame challenges in the past. What kinds of resources did you call upon then? Which of those are available to you now?

You have some great ideas, would you mind if we wrote them down on to keep with you as a reminder? Will you summarize the steps you will take to change your [X] use?

Identify strengths & supports

5. Prescription for Change

Write down action plan

Creating an Action Plan

How does it all fit together?

Video Demonstration

http://www.sbirtnc.org/

Brief Intervention and Referral Description

Clinician advises further assessment and treatment from a specialized facility or resource

Method Referrals can be advised as part of the intervention Clinic staff will actively facilitate the referral

Purpose Motivate and engage patients to see further

assessment and/or treatment as part of the brief intervention.

Does Treatment Work?Providers sometimes feel discouraged about referring patients for substance abuse treatment. Sometimes it seems like it just isn’t worth the effort. But relapse rates are really no different than other chronic diseases:

http://www.nida.nih.gov/PODAT/faqs.html#Comparison

Referral to Treatment Guidelines To maximize the likelihood of success, assess level of

care needed Determine if patient is drug or alcohol dependent (and

needs medical withdrawal) (inpatient) or is a substance abuser (outpatient unless has other risk factors)

Determine if patient has other risk factors that would make them better candidates for inpatient treatment than outpatient treatment:

• Co-occurring mental illness (may need a psychiatry consult)

• Polysubstance use and dependence on multiple substances

• Serious medical illnesses that may be exacerbated when substance use changes

Other Factors to Consider

Insurance coverage Private: must check with insurer to determine

what kind of treatment and what facilities they will pay for

Public assistance (VA vs. TN Medicaid)Language ability/cultural competenceTreatment history (have they failed outpatient

treatment in past?)Location/transportation: can the patient and their

family easily access the treatment facility?

Other Factors to ConsiderFamily supportCan the facility treat both substance use disorders

and mental illness?Can the facility treat both substance use disorders

and medical illness?Does the facility offer/support pharmacotherapy

for maintenance of abstinence?Does the facility have a good record of keeping

referring medical staff informed of patient progress and ongoing needs?

Common Roadblocks/Mishandling PCP rushes into “action” and makes referral when the patient

has no interest PCP refers to an program unable to accept patient due to

capacity or doesn’t take the patient’s insurance Patient feels unheard and frustrated

PCP doesn’t create a referral “package” Other strategies/programs patient can try while they are on

a program PCP doesn’t consider pharmacotherapy to reduce cravings

and/or reduce suffering PCP gets frustrated and sees the patient as “resistant” or

“self-sabotaging” Versus having a difficult chronic disease

What could you do to avoid each of these mistakes? How will you assess your success?

Key Points for BillingPre-screen

Front desk personnel, triage nurses, etc. Not reimbursable SBIRT services

Full Screen Physicians, physician assistant, nurse

practitioner Licensed behavioral health care practitioner

• Clinical social worker• Psychologist• Professional counselor

Key Points for Billing - Scenario PCP sees a new patient with a chief complaint relating to

physical health Primary care office administers pre-screen for drug and

alcohol abuse Negative – document negative pre-screen and do not

pursue further SBIRT services; no SBIRT billing Positive – may conduct Full Screen and Brief

Intervention Service• Bill under regular E&M code for the primary

complaint• SBIRT service code either 99408 or 99409,

depending on time

Key Points for Billing - Scenario If Full Screen is negative

May choose not to pursue further SBIRT services• No billing would occur• Billing for services would be under E&M billing

codes, depending on time and complexity of primary health service

May choose to provide general feedback, prevention counseling, discuss risky lifestyle choices, self-management

• Bill under SBIRT codes – 99408 (15-30 minutes)– 99409 (greater than 30 minutes)

Key Points for Billing - ScenarioIf Full Screen is positive

May provide more complete screening and brief intervention services

• Billing under SBIRT codes may occur AND

• Billing for primary health services under E&M codes may occur

Key Points for Billing - ScenarioIf SBIRT service experience indicates need for

specialized alcohol and drug abuse services Provide services from internal behavioral

health/addiction specialist OR Refer patient to outside addiction specialist SBIRT codes may NOT be used since

services are beyond scope of Brief Intervention Services authorized

Coding for SBIRT ReimbursementPayer Code Description Fee Schedule

Commercial Insurance

CPT 99408Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

$33.41

CPT 99409Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

$65.51

Medicare

G0396Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

$29.42

G0397Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

$57.69

Medicaid

H0049 Alcohol and/or drug screening $24.00

H0050 Alcohol and/or drug service, brief intervention, per 15 minutes $48.00

http://www.samhsa.gov/prevention/sbirt/coding.aspx

Helpful ResourcesSBIRT Training : Skills Training for Primary Care

Providers http://www.sbirttraining.com/

SAMHSA’s Motivational Interviewing Training Website http://www.motivationalinterview.org/index.html

SAMHSA’S Screening, Brief Intervention and Referral to Treatment website http://www.samhsa.gov/prevention/sbirt/

Helpful ResourcesSubstance Abuse Screening, Brief Intervention and Referral

to Treatment North Carolina http://www.sbirtnc.org/

Resource documents (screening tools, presentations, publications) at the University of Texas Health Sciences Center School of Medicine http://familymed.uthscsa.edu/sstart/resourcesOPEN.asp

SAMHSA Mental Health Services Locator http://store.samhsa.gov/mhlocator

Helpful ResourcesInstitute of Substance Abuse Treatment Evaluation:

Tennessee Outcomes for Alcohol and Drug Services (TOADS) http://www.isate.memphis.edu/treatment.html

Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians http://pediatrics.aappublications.org/content/

128/5/e1330.full.html

Sarah T. Melton, PharmD,BCACP, BCPP,CGP,FASCP

Screening, Brief Intervention and Referral to Treatment (SBIRT) in the Primary Care Setting

16th Annual Primary Care ConferenceMonday , March 26, 2012

Millennium Centre, Johnson City, TN